Prevalence of Independence at Home–Qualifying Beneficiaries in Traditional Medicare, 2014-2021

Key Points Question Has there been growth in the high-needs, Independence at Home (IAH)-qualified population in traditional Medicare (TM) between 2014 and 2021, and how does the size of the IAH-qualified population in TM compare with Medicare Advantage (MA)? Findings In this cohort study, the IAH-qualified beneficiary population in TM grew from 2.16 million in 2014 (6.4% of TM) to 3.27 million in 2021 (10.7% of TM). In TM, the IAH-qualified population accounted for 44% of Parts A and B TM spending in 2021 vs 29% in 2014; the proportion of the IAH-qualified beneficiaries was 33% larger in TM than in MA. Meaning These results suggest that the IAH-qualified subset of the TM population and their share of TM spending has increased; MA is not disproportionately caring for such high-need beneficiaries, despite programmatic features to facilitate such care, an observation that reinforces the need for accessible high-needs clinical programs for IAH-qualified beneficiaries in TM.

The difference between the Evaluation cohort results and the Evaluation reports is that the Evaluation used a difference in differences approach, so could only address the question of the impact of the IAH payment incentive on changing the difference between IAH qualified HBPC patients and their controls, as over 70% of participants were receiving HBPC before entry into the We use two different frailty indices, at two different time points: the JEN frailty index in 2014 1 , and the JEN frailty index (JFI) and the Kim Claims Frailty (CFI) index in 2021.The use of the CFI for the Medicare Advantage cohort was necessitated due to the proprietary JFI license limitations, precluding Dr. Yao's access.
To calibrate the instrument thresholds, we used the 2021 CMMI High Needs ACO REACH definition of a high needs population, which we had previously shown was equivalent to an IAH qualified population in 2021, using a JFI threshold of 6+ in 100% Traditional Medicare claims data 2 .
For computation ease, we used the 5% flag in the Medicare claims for further calibration analyses.
We replicated the 2021 HN-IAH qualified comparison in the 5% file.We then identified the CFI threshold which would identify the same share and characteristics of the TM population as IAH Qualified.That threshold was a CFI of .20,with similar differences from HN ACO REACH to the IAH qualified identified by a JFI 6+.

(E-Table A-1)
We also compared the subset of patients identified by either JFI 6+ or CFI=.20 who did not overlap with the HN population.Those patients are also nearly identical.

(E-Table A-2)
We then compared the CFI .20 population in MA with the TM JFI 6+ IAH qualified population and the general TM population.(E- reports Y4-8 (Evaluation Change in Savings), and with Evaluation cohort results taken from Appendices in the Evaluation reports (Evaluation Savings), detailed in Deligiannidis KE, Boling P, Taler G, Leff B, Kinosian B. Independence at Home: After 10 years of evidence, it's time for a permanent Medicare program.J Am Geriatr Soc.2023; 71(9): 3005-3009.doi:10.1111/jgs.18386

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2024 Lally T et al.JAMA Network Open.demonstration.The Evaluation cohort results compares the demonstration beneficiaries with their matched control cohort, without removing the prior effect of HBPC (the central part of the IAH care model).The CMS net savings are the Evaluation cohort savings, less the shared savings paid to the practices.A: Alignment of JEN Frailty Index and Kim Claims Frailty Index to identify IAH qualified Medicare Beneficiaries in TM and MA.

Table E1 IAH
Demonstration Savings Results: Announced Savings, Evaluation Cohort Savings, and the Change in Savings from the Payment IncentiveTable above combines annual CMS savings announcements (Actuarial savings), with Evaluation

Table A -3) VARIABLE_DESCRIPTION TM Population TM IAHQ (JFI 6+) MA CFI=.20
The MA IAH qualified population is more female, younger, more non-White, and with lower prevalence of dementia than the TM IAH qualified population.Importantly, for concerns about upcoding in MA HCC scoring affecting the CFI calculation, the mean CFI score is equivalent between MA and TM (.29), although the differential share of patients with dementia (39% TM vs 30% MA) suggests a different mix of conditions contributing to the frailty score in the two populations.1. Orkaby AR, Huan T, Intrator O, et al.Comparison of claims based frailty indices in US veterans 65 and older for prediction of long-term institutionalization and mortal-ity.J Gerontol A Biol Sci Med Sci.2023;78:glad157.doi:10.1093/gerona/glad1572. Taler G, Boling P, Deligiannidis KE, Kubisiak J, Lee A, Kinosian B. High needs criteria in High Need Accountable Care Organization Realizing Equity, Access, and Community Health inequitably limits access to equally high-need Medicare beneficiaries.J Am Geriatr Soc.2023 Oct 29.doi: 10.1111/jgs.18651.Epub ahead of print.PMID: 37898982.